CY Liu - Ureter

Thank you Endofound for putting on this superb endometriosis meeting and thank you for the invitation. My topic this afternoon is Laparoscopic Treatment for Ureteral Endometriosis. But first, since this morning after Dr. Ron Batt talked I told him we should pay tribute to two pioneers in endometriosis research back in the 1920s. The first one of course is John Sampson. I just happened to have pictures in my computer, they comes in handy. This is his original paper back in I believe 1923/24 talking about peritoneal endometriosis due to the menstrual dissemination of endometrial tissue, he did not say endometrial blood, into the peritoneal cavity. This is his original drawing on the paper. Talking about endometrial tissue and I have done probably 1000 laparoscopic surgeries and I was intentionally looking for… endometrial tissue coming up from the tube but I have never seen any. I see a lot of menstrual blood but not…endometrial tissue.

A friend of mine, Ray Gary, in England, he sent me this slide. Do you see here, I have never seen something like this…several thousand patients. He also sent me these slides proof it is endometrium. It is not difficult, and it is logical, to accept that living endometrial tissue would implant seeding on the peritoneal surface and it can even grow and spread into the pelvic organs.

The second person is a pioneer back in the 1920s, Thomas Cullen who was Canadian. He became the professor of gynecology at Johns Hopkins in 1919 to 1939. His paper basically talked about adenomyosis of rectovaginal septum. Ron (Batt) said it is rectal cervical adenomyosis. Now he was talking about in part again about hematological spread for distant endometriosis. But again, we understand better now, after Dr. Batt’s lecture this probably is müllerianosis or embryonic pathogenesis, whatever it is Ron talked about it this morning. That was an excellent talk.

But with these two pioneers’ work they are thinking their hypothesis I am going to talk to you about ureteral endometriosis. Here is a picture. We are talking about this, ectocervical adenomyosis imbedded into the ureters. In this kind of case you have to do a hysterectomy. Years ago we had a concept “oh, endometriosis – no hysterectomy” endometriosis is extrauterine disease. You need to excise it, do not take out the uterus. In this case, if you do not take out the uterus she is not going to get better.

Here is Thomas Cullen’s original picture showing all those distal endometriosis away from the pelvis. Now we understand there is acquired and congenital müllerianosis.

But with endometriosis involved with the ureter – same thing – two types of involvement; one is from external that comes to the ureter, what is involved is basically the capsule of the ureter. It is very seldom you see them invade in the muscularis. So the treatment for that kind of endometriosis of the ureter is ureterolysis.

You can see a lot of endometriosis from outside. Here is an ovary and the sigmoid colon, the upper part of the sigmoid colon is separated so I try to identify the ureter. Now, the ureter is right here, it can be identified. And here is a chunk of endometriosis again. So you open up the peritoneum overlying the ureter, dissect the ureter down towards the cul-de-sac. You can see here is all the endometriosis. I am pulling on the ureter. The ureter is very tough. You can pull on it, you can tug it and here is all the scarring. You can see – I use a CO2 – that was back in 1990s. You can see the uterine artery right here. It also grew to the ureter. This patient was only 32 and wanted to have a baby. We do not want to sever the uterine artery so we separated the uterine artery from the ureter. So be very careful about not getting into bad bleeding. You can use the scissors of course for excise surgery too. Slowly separate it. My point is that this type of endometriosis, ureterolysis is sufficient. If this patient had gone to a urologist I do not know if they would do that they probably would have done a resection. By the way, urologists hate endometriosis. You call them to help you with endometriosis and they say no.

I want you to pay attention to this area you see the scarring here. You see the adhesive band but the ureter – this only involves the capsule. The ureter per se is okay, normal. So take time to cut loose all these adhesive bands. The ureter is back to normal. You see the band right here? Just take time to cut it the ureter has not been damaged. You just need to be patient to do this.

The second case scenario is different. This is endometriosis involved in the muscularis layer. This is like Thomas Cullen’s theory. When you look into the pelvic cavity part of it is clean, there is not much endometriosis at all. In this case the endometriosis – I want you to see – here is a big tube almost like an external iliac vessel but note the movement of the tube from up to down. The only organ that moves like that is the ureter. It is hydroureter. This patient in a sense is a little bit fortunate because it is acute onset and the urologist suspected probably endometriosis so he referred to me. We work with urology very, very closely.

Give me a clue, is this the hydroureter of course she had IVP and this is the only place the pelvis was clean. It is not from external, Sampson’s Theory may not work in this case but Cullen’s theory will work. We dissected there and right here. Endometriosis surgery always involves a lot of dissection. Here you see – it is not too clear is it – this area only the proximal and distal part of the ureter is practically normal. You see this big obstructive site? Obviously this is already into the muscularis. Here – see again? Very obviously, right here that is the only way we can do this – segmental resection.

Segmental resection of course you can do a tangential cut and then do reanastomosis but remember laparoscopic surgery is microsurgery, you do not have to do that you can just cut like this. Then with microsurgical technique you can do reanastomosis. We repair the ureter like we are doing tubal reanastomosis, the first stitch is at 6 o’clock and then 12 o’clock, then 2 and 4 o’clock and 8 and 10 o’clock. The 6 and 12 o’clock you cut the suture long so it can twist and turn around. Of course you want to do a tension free reanastomosis so you want to dissect the ureter all the way above the pelvic brim. Try to preserve as much ureter as possible. You do not want to cut the pathological part. I am preparing it. All my life I tried to avoid the ureter. Now that I have a chance to intentionally cut the ureter I feel good about that. That is what happened. I take out the scissors and just cut it. You see the ureter is very happy too. It is an instant relief. Then the hydroureter strengthened right away and the distal part again I dissected to the bladder here. Let me make a comment.

We know the ureter got into the bladder wall traverse about 1.5 to 2 cm on the bladder wall. Many times if this is too close to the bladder you can actually pull the ureter out of the bladder wall. Give you a better lens and less tension there. Anyway, the same way try to save as much healthy ureter as possible and of course send this to pathology. That is what obstructed.

Then you can do reanastomosis – this is the ureter stand, whether you want to do that or not is not important because we are doing microsurgery. Using the microsurgical technique for the tubal reanastomosis you do 6 o’clock, 12, 4, 2, 8 and 10 o’clock. The ureteral reanastomosis actually is easier than tubal reanastomosis. Tubal reanastomosis we try to avoid endosalpinx. Ureter reanastomosis all you do is through and through, okay, the hot air and the key point is to make sure you have a big bite. When you tie the suture without undue attention, do not tie too tight. All you want is re-approximate it and make sure the anastomosis side is tension free. See how big a bite and I tie 6 o’clock first, instrument tie. You see a macro laparoscopic instrument not even a micro surgical instrument. Then 12, 2, 4, 8 and 10 o’clock. Leave the 6 and 12 suture long so it can rotate. After that have a urologist put the double J in, usually they keep it for about six weeks. Then the patient can go back to see the urologist in six weeks and they will take it out the double J and do IVP there and make sure there is no stricture. If there is no stricture they will do another IVP in three months and then one year after that. So far we have had very good luck with this type of surgery. We have done probably about, I believe16, not all endometriosis cases. But so far everything has gone on successfully so we must be doing something right. Again, deep, big bite without undue attention when you tie the knot make sure there is no tension on the anastomosis side. Whether you put a drain at the end of surgery is not important because laparoscopically they are doing well and hardly have any kind of drain – we should put it in and take it out the next day. With the double J there it is pretty safe

That is my talk, I would be happy to take some questions.

Audience member: Is your incision circular or do you make it fish mouth?

CY Liu, MD: No, usually you do not. As I said the laparoscopic surgery is microsurgery. You do not need to but you can do either tangential and if you think one, for example hydroureter is so big, the other one small, you can make a fish mouth and then close it, which is an option. But from my experience I have not had to do that.

Ray Wertheim, MD: I have a question and a comment; the first is a question, what suture do you use?

CY Liu, MD: Okay, the suture usually is a 60 PDS and in all I do not think it is that crucial. You can use, if you want to use, a 40 VICRYL would probably be okay, because this is not as crucial as tubal reanastomosis. With a tubal reanastomosis you get into endosalpinx, they have a higher chance of getting ectopic because of the scarring but the ureter is so good, like a wife or husband, always forgive you as long as you pay attention to them.

Ray Wertheim, MD: Then I just have one comment. Most of my cases are pelvic pain and endometriosis. On every hysterectomy I use the retroperitoneal approach and I will open up the broad ligament and look at the ureter. It is amazing how often that retroperitoneal space is scarred and I will loosen that ureter up all the way down to prevent any endometriosis from harming that ureter.

CT Liu, MD: Right, but endometriosis from outside coming in be very careful. When they have, like my first case, the ureter is always being pulled toward the uterosacral ligament. Always, almost no exception, you have got to dissect it. The best time to learn how to dissect the ureter is in a normal condition. Any other questions?

Audience Member: I actually have a comment. I think that doing surgery on the ureter and the bladder is always a little tricky. If you have a complication the urologist is now coming in afterwards and having to sort of see what to do. It is always a good idea, I think, if you have a urologist around to stick their head in and see what is going on and see what kind of stent they want to leave, how big the stent should be, the drains, so that if there is an issue in the future they have had some interaction and some idea of what happened in the original surgery.

CY Liu, MD: Always call the urologist. You know why? Another reason is that they will share your legal responsibility.

Audience Member: Major medical legal issue for sure.

Harry Reich, MD: Let me make a comment here because I think it is important because the Europeans, if you ever take a course on endometriosis with Arnaud Wattiez in Strasbourg – they are starting to dissect the ureter in every endometriosis case, both ureters to develop the pararectal space. It is hard to bring in a urologist you have to work… What do you think of this concept?

CY Liu, MD: Harry, in my fellowship program, in my first year program, I have a fellow dissect a ureter, in every case by the way, necessary or unnecessary. They have to learn. If they do not learn in a benign case when they have a difficult case they do not know what to do. They have to feel comfortable. The ureter and the bladder are very, very forgiving.

Harry Reich, MD: One last question. I saw you had a drain, put in a drain. You know my philosophy after well over 50 abscess cases and bowel resections. They key is to talk to the general surgeon out of putting a drain in because… are going to get stuck together.

CY Liu, MD: The only reason I put a drain in was because my urologist insisted. JP or…I do not. I said there was no reason because a laparoscopic repair is…

Audience Member: Most of us nowadays with re-implants do not drain and do not stent. We do not do either.

CY Liu, MD: Anyone else? Tamer?

Tamer Seckin, MD: Well, in Europe – we do it here too Harry. Really, this is New York – one of the most important things is you have to know the urologist and the urologist should be familiar with the work. You cannot call them in when there is a problem. Usually in stage four cases, even though I do not need it, but it gives me speed and more precise dissection, I have him put the stent in so I move fast. In the end sometimes I leave a J stent prophylactically. In some cases you really go into the wall, you put in a stitch. Many times, every case there is a diffuse ureterolysis, every case. And the other thing is I think the drain issue is very critical, especially if two orifices are entered, whether it is ureter, rectum repair some simultaneously or vaginal cuff, please do not put a drain there or anything. Make sure there is a pedicle you bring there because the chance of fistula is tremendously high.

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